It's Kidneys, Doc, Kidneys!

I really did get emails from one reader who lost her brother to kidney disease and who claimed she didn't know that ESRD is covered by Medicare. She thought it was the wonders of the market. I wonder if she's tried to purchase health insurance lately. I figure it can't hurt to confront these libertarians with reality every now and then.

Most of the statistics in this column came, directly or indirectly, from Medicare’s End Stage Renal Disease Program, by Paul W. Eggers, Ph.D. of the National Institute of Diabetes, Digestive, and Kidney Diseases at NIH, published in Health Care Financing Review (Fall 2000). Additional background on the political origins (and need for) the ESRD diagnosis can be found in Daniel M. Fox, Power and Illness: The Failure and Future of American Health Policy (University of California Press, 1993), at 76-77.

Bonus points if you know the setup to the punchline above, provided you're no longer in elementary school.

C'MON, ADMIT IT: SOMETIMES, GOVERNMENT IS THE SOLUTION
East Valley Tribune, Dec. 24, 2006

Some Bush-supporting dead-enders, upset at criticism of the Iraq war, have demanded the name of one government program that actually works. So let’s consider the Medicare end stage renal disease (ESRD) program. It’s not perfect, but since 1973, over 1 million people have had their lives extended or saved -- by socialized medicine.

Even people who should know better don’t understand how dialysis and kidney transplants became widely available. One reader lost her brother to kidney disease forty years ago; she thought market forces made dialysis cheaper, just too late for her brother. She simply didn’t know -- or her ideology wouldn’t let her know -- that it was government’s doing.

Today’s dialysis machines date back to 1960, and successful kidney transplants from cadavers became common a few years later -- early enough that her brother might have been saved. But until 1973, treatment was extremely costly; dialysis machines were rare, and most health insurance didn’t cover such "experimental" treatments. Physicians rationed care, deciding whether the mother of young children, or the older business executive, or the teenager should get the last dialysis slot. If you didn’t win, you died.

Not surprisingly given a subjective rationing system, patients getting dialysis didn’t quite reflect the population with kidney disease. In 1967, patients were overwhelmingly male (75 percent), white (91 percent), and young (only 7 percent 55 or older). By 1978, after the government became involved, patients were evenly balanced between men and women, blacks represented 35 percent, and 46 percent were 55 or older.

It took about a decade for the political system to make kidney care widely available. A Johnson administration advisory committee concluded that the benefits of dialysis and kidney transplantation far exceeded the disease’s costs. Five years later, Congress amended Medicare to cover ESRD -- a political diagnosis essentially invented to convert a chronic disease into an acute condition so it Medicare could cover it.

The ESRD program kept expanding, both in terms of coverage and patient numbers. Part of the latter increase comes from the dramatic increase in diabetes incidence; in 1978, 10 percent of patients in ESRD program had kidney failure from diabetes, but by 1998, 45 percent did. Additional advances also have allowed more medically fragile patients, and especially patients over age 65, to receive dialysis. Finally, Congress has expanded the program several times, although per capita and inflation-adjusted reimbursement rates are considerably lower than twenty years ago.

Not everybody qualifies for ESRD treatment under Medicare; it’s an entitlement only for those fully or currently insured for Social Security benefits, or a spouse or dependent. But those are not exacting requirements, so approximately 92 percent of persons with ESRD qualify for Medicare coverage. Thus, we have nearly, but not quite, universal coverage for nephritis under a socialized system, where every wage earner’s Social Security taxes help fund medical care for everybody, regardless of means, suffering from end-stage renal disease.

Yes, people who should know better don’t understand the role that government played in making dialysis and transplants widely available, so that losing kidney function wouldn’t mean death unless you won the rationing lottery. You’ll see ‘wingers complain about restrictions on dialysis in New Zealand, without acknowledgement that dialysis is widely available in the U.S., especially to elderly patients, only because Medicare covers it.

Ask anybody with kidney disease if they want to go back to the way life was in 1972, before big, bad government got involved. Start with those 1 million people who had their lives extended by Medicare; ask if they want to return to having doctors decide who shall live and who shall die.

Medicare ESRD is a government program of socialized medicine. It’s not perfect; lots of advocates want better reimbursement, especially for home dialysis, and there have been lots of not-nearly-as-successful government programs. But the next time you mindlessly parrot that government’s the problem, remember Medicare ESRD and those 1 million people.

As Matthew Holt once put it, remember that government spending led to the creation of the Internet and biotechnology; the market created reality TV.